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Form from www.needymeds.org Reset Form Provider Authorization and Confidentiality Agreement I , hereby request that I be provided access to the XELSOURCE HCP Portal.* I certify that I have submitted.

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How to fill out the Xelsource Patient Portal online

The Xelsource Patient Portal enables healthcare providers to access important patient information securely. This guide will walk you through the process of completing the necessary authorization form to access the portal.

Follow the steps to complete your authorization request

  1. Click the ‘Get Form’ button to obtain the authorization form and open it for editing.
  2. In the first section, fill in your details by providing your first name, last name, and NPI number. Ensure that all information is accurate to avoid processing delays.
  3. Specify your role in the healthcare setting by selecting one of the options: 'Healthcare Provider' or 'Office Staff'.
  4. Complete the address section, including the street address, city, state, and ZIP code.
  5. Enter your email address to ensure you receive important communications regarding your access to the portal.
  6. Review the confidentiality agreement. You will need to acknowledge your understanding of protecting the contained health information before you can proceed.
  7. Sign and date the healthcare provider signature section. This step is crucial for your request to be processed.
  8. After filling out the form, fax the completed document to 1-866-297-3471. The requests will be evaluated within 1-2 business days.
  9. Upon processing, you will receive two separate emails: one with your log-in ID and the other with your password for accessing the portal.
  10. Finally, save your changes, download a copy for your records, or print the form as needed.

Complete your form online today to gain access to the Xelsource Patient Portal.

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Contact support

Pfizer RxPathways connects eligible patients to assistance programs that offer insurance support, co-pay† assistance, and medicines for free or at a saving. Learn more by visiting .PfizerRxPathways.com or calling 1‑844‑989‑PATH (7284).

This is a brand name drug and a generic may be available. The average cost for 1 Bottle, 60 tablets each, is $5,889.05. You can buy at the discounted price of $5,501.71 by using the WebMDRx coupon. Even if this drug is covered by Medicare or your insurance, we recommend you compare prices.

Sign up for the Co-Pay Savings Program, if Eligible If you are unable to confirm your eligibility or have additional questions, call XELSOURCE at 1-844-935-5269. For eligible underinsured or uninsured patients, XELSOURCE may offer financial assistance through the Pfizer Patient Assistance Program.

Brand-name drugs can be expensive because of the research needed to test their safety and effectiveness. The manufacturer of a brand-name drug can sell it for up to 20 years.

Medicare prescription drug plans typically list on Tier 5 of their formulary. Generally, the higher the tier, the more you have to pay for the medication.

is covered for 79% of eligible Medicare patients. Check directly with health plans to confirm coverage for individual patients. The information provided is not a guarantee of coverage.

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